Tuesday, March 25, 2008

Dr. Rob -Health Care is not a system-so how will the medical home work?

The latest entry by Dr. Rob puts forth the notion that various advocates for medical care change ( single payer advocates or let the market have at it) tend to talk about a system and there is no system. There are multiple independent or variably dependent entities typically working in ignorance or purposeful disregard of the other's actions and influences and do their various jobs in often what is a myopic, self contained sphere of activity that sometimes only incidentally benefits either the patient of the health care provider ( forgive me for the designation) and too often does little good for either.He gives us a revealing thumb nail sketch of many of the players ( primary care docs, ERs, specialist, medical insurers, etc) that hits many nails on the heads. Whatever you can say about health care in the this county you cannot say it is coordinated.

All of this seems so obvious that I continue to fail to see how the increasingly hyped ACP version of the "Medical Home" would work wherein somehow the primary care doc (an internist if you go along with the ACP-United Health Care version of this latest dressed up P4P) would somehow accept responsibility for the comprehensive care of the patient. As long as the patient has the freedom to see whomever for whatever ( e.g. a orthopedist for his swollen knee who then sends him off for a MRI and PT outside of the watchful,comprehensive caring eye of the homie) the medical home doc cannot control the situation and therefore cannot reap the benefits of controlling cost, in the absence of which United HealthGroup would not be a player to begin with. It is looking more and more like a HMO-oid situation with a touch of P4P thrown in , significant restrictions on what the patients- and the doc - can do, plus a dollop of electronic records and a giant heaping of guidelines which will be more toothy than guidelines and a lovely icing of "continuous quality improvement" verbiage to suck in the corporate employer clients.

It does seem to be getting some traction as discussed in this latest press release from ACP which brags about recent grants received from Pfizer and others to study and implement the medical home plan.

The UHF and Pfizer grants, in addition to a grant awarded to ACP by the Commonwealth Fund in late 2007, will help ACP continue the design and implementation of practice-based resources for internists and their office teams. ACP Executive Vice President and Chief Executive Officer John Tooker, FACP, said the grants are an indication of how the model of care could be here to stay. “The patient-centered medical home, in coordination with the other components of the health care delivery system, is the future of health care,” he said.

6 comments:

you don't just need an information system. you need everyone to sacrifice their healthcare freedoms to make it work.

the more these societies partner with insurance companies the less i trust them. i'm not even sure these societies understand how the practice of healthcare works for most americans. certainly there are exceptions, but the people who have time to be actively involved tend to be academics who have no idea on billing, receipts, practice management, liability mitigation, etc.

Omygosh, this is an "Ivory Tower" (see Dr. Rob) solution that will plan to have the "Medical Home" doc coordinate the patient's care. Great idea. But they plan to pay minimum wage for the coordination: "Someone in your office can call .. . .."

As soon as it is put into place, the first year will cost more ("start up always costs more," per MBA training), the second year will make the planners worry about cost and the third year will see many other insurors doing the same because of of publication about the "potential." By year five, insurors will simply make reductions in payment for that coordination. In year three to six, the "medical home" coordinating internists will drop out in droves--losing more each year. A few internists will hang on as the true believers as the program winds down.

When England went to their PHS in the 50's they foresaw this. They captured patients on lists. GP's got lists of patients that they had to deal with, when before the patients would just shop around for a different provider, which is what goes on here now. Doctor shopping can be good, but I also see the druggies all find Dr. Feelgood and the worried find their Idol Father figure... And who can say if the "health" is improved or not....We SURE spend alot...But then Americans spend alot on cars, TV's and snomobiles too.

It won't work at all, regardless of information coordination, as physicians will take less money in exchange for not codifying the reality of primary care as the dumping ground/mother hen for specialists. Also, highly motivated patients will self-select for retainer medicine as it becomes more readily available. You will be left with 317's (imbeciles) who cannot remember to change their automobile oil. I have some that get lost in my parking lot.

The American Academy of Pediatrics and the National Initialtive for Children's Healthcare Quality has been working on the medical home concept for years, and we're starting to see great results. The purpose of the medical home is to provide high quality, patient centered care -- cost savings are secondary, and come through appropriately managing chronic health conditions so as to avoid ED visits, hospitalizations, duplication of services, etc.